Instructions for Form DHCS100185 "Drug Medi-Cal (Dmc) Claim Submission Certification - Direct Contract Provider" - California

This document contains official instructions for Form DHCS100185, Drug Medi-Cal (Dmc) Claim Submission Certification - Direct Contract Provider - a form released and collected by the California Department of Health Care Services. An up-to-date fillable Form DHCS100185 is available for download through this link.

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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR DRUG MEDI-CAL (DMC) CLAIM SUBMISSION CERTIFICATION - DIRECT CONTRACT PROVIDER
DHCS 100185
GENERAL
The DMC Claim Submission Certification form for Direct Contract Providers is used to certify the submission of Drug Medi-Cal claims to DHCS by a provider
contracting directly with the State. This form must be completed and submitted to DHCS for EACH EDI file containing DMC claims submitted by the direct contract
provider. A copy of the (if the form is faxed to DHCS, the original copy) must also be retained by the provider and made available to DHCS on demand.
NOTE: PAYMENTS WILL NOT BE RELEASED UNTIL THE CERTIFICATION FORM IS RECEIVED BY DHCS.
HEADING INSTRUCTIONS
a. PROVIDER NAME (LEGAL ENTITY): enter the name of the provider performing the service.
b. FEDERAL TAX IDENTIFICATION NUMBER: enter the federal tax identification number of the billing provider.
c. EDI FILE NAME: enter the name of the EDI file in which the claims certified on this form were submitted to DHCS for processing.
SIGNATURE BLOCK INSTRUCTIONS
One original signature is required on the DHCS 100185, that of the authorized claim submitter.
a. PRINTED NAME: AUTHORIZED CLAIM SUBMITTER: print the name of the authorized service provider.
b. SIGNATURE: AUTHORIZED CLAIM SUBMITTER: signature line for the authorized service provider.
c. PHONE NUMBER: enter the area code and phone number of the authorized service provider.
d. DATE SIGNED: enter the date the form was signed by the authorized service provider.
SUBMISSION OF DHCS 100185
DHCS 100185 with original signature and date may either be faxed to (916) 322-1176 or mailed to:
Department of Health Care Services
Substance Use Disorder Prevention, Treatment and Recovery Services Division
Fiscal Management and Accountability Branch-MS 2629
P.O Box 997413
Sacramento, California 95899-7413
DHCS 100185 Revised 6/2014)
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR DRUG MEDI-CAL (DMC) CLAIM SUBMISSION CERTIFICATION - DIRECT CONTRACT PROVIDER
DHCS 100185
GENERAL
The DMC Claim Submission Certification form for Direct Contract Providers is used to certify the submission of Drug Medi-Cal claims to DHCS by a provider
contracting directly with the State. This form must be completed and submitted to DHCS for EACH EDI file containing DMC claims submitted by the direct contract
provider. A copy of the (if the form is faxed to DHCS, the original copy) must also be retained by the provider and made available to DHCS on demand.
NOTE: PAYMENTS WILL NOT BE RELEASED UNTIL THE CERTIFICATION FORM IS RECEIVED BY DHCS.
HEADING INSTRUCTIONS
a. PROVIDER NAME (LEGAL ENTITY): enter the name of the provider performing the service.
b. FEDERAL TAX IDENTIFICATION NUMBER: enter the federal tax identification number of the billing provider.
c. EDI FILE NAME: enter the name of the EDI file in which the claims certified on this form were submitted to DHCS for processing.
SIGNATURE BLOCK INSTRUCTIONS
One original signature is required on the DHCS 100185, that of the authorized claim submitter.
a. PRINTED NAME: AUTHORIZED CLAIM SUBMITTER: print the name of the authorized service provider.
b. SIGNATURE: AUTHORIZED CLAIM SUBMITTER: signature line for the authorized service provider.
c. PHONE NUMBER: enter the area code and phone number of the authorized service provider.
d. DATE SIGNED: enter the date the form was signed by the authorized service provider.
SUBMISSION OF DHCS 100185
DHCS 100185 with original signature and date may either be faxed to (916) 322-1176 or mailed to:
Department of Health Care Services
Substance Use Disorder Prevention, Treatment and Recovery Services Division
Fiscal Management and Accountability Branch-MS 2629
P.O Box 997413
Sacramento, California 95899-7413
DHCS 100185 Revised 6/2014)